Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 56928 | CA |
NPI | 1154547966 |
---|---|
Provider Name | Monica Lara Cordoba |
First Address | San Francisco, CA 94102-1411 |
Second Address | San Francisco, CA 94102-1411 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2007 |
Last Update Date | 15/12/2015 |